Large Intestine

 

Clostridium Difficile Colitis

review article from NEJM

when to consider surgical consultation

Clostridium Difficile Infection

Emergency Physicians frequently encounter patients with Clostridium difficile associated disease (CDAD) and should be aware of the following:

Enzyme immunoassay is the preferred diagnostic assay because the technique is relatively simple. Despite good specificity (up to 99%), EIA is reported to have only moderate and variable sensitivity (60 – 95%).

Metronidazole should be used for initial treatment of non-severe CDAD. The recommended dose is 500 mg tid or 250 mg qid for 10 -14 days.

Relapse is defined by complete abatement of symptoms while on appropriate therapy, followed by subsequent reappearance of symptoms after treatment has been stopped.

• Relapse occurs in 10 – 25% of cases treated with metronidazole or vancomycin. Most relapses occur within 1 -2 weeks after discontinuing antibiotic therapy. Antibiotic resistance does not appear to be a factor in relapse.

• Initial relapse should be treated with metronidazole; subsequent relapses are treated with vancomycin followed by rifaximin

Severe disease – Patients with acute C. difficile infection may develop signs of systemic toxicity warranting admission to an ICU.

• Practice is shifting toward using oral vancomycin (125 mg qid) as initial therapy for severe CDAD.

• Severely ill patients may have markedly delayed passage of oral antibiotics and may benefit from the addition of IV metronidazole because of biliary and intestinal excretion of the drug. In contrast, IV vancomycin has no effect on C. difficile colitis since vancomycin is not excreted into the colon.

• Some severely ill patients with CDAD require emergency colectomy because of toxic megacolon-associated ileus, impending perforation, or refractory septicemia.

IV immunoglobulin contains C. difficile antitoxin and has been used in some patients with relapsing or severe C. difficile colitis. Although there are case reports suggesting IVIG may be a useful addition to antibiotic therapy for refractory CDAD, its use is still controversial.

References: (1) Blossom, DB, McDonald, LC. The challenges posed by reemerging Clostridium difficile infection. Clin Infect Dis 2007; 45:222. (2) Nielsen, ND, et al. Changing epidemiology of Clostridium difficile-associated disease. Infect Dis Clin Pract 2006; 14:296. (3) Salcedo, et al. Intravenous immunoglobulin therapy for severe Clostridium difficile colitis. Gut 1997; 41:366. (4) Fekety, R. Guidelines for the diagnosis and management of Clostridium difficile- associated diarrhea and colitis. American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol 1997; 92:739. (5) Zar, FA, et al. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis 2007; 45:302.

EMEDhome

 

The current CMAJ has an important article about C diff – Patterns of antibiotic use and risk of hospital admission because of Clostridium difficile infection

C diff now enters the differential diagnosis in patients presenting with sporadic diarrhea, even without recent antibiotic exposure.

Of the 836 cases, 442 (52.9%) had no exposure to antibiotics in the 45-day period before the index date, and 382 (45.7%) had no exposure in the 90-day period before the index date. Antibiotic exposure was associated with a rate ratio (RR) of 10.6 (95% confidence interval [CI] 8.9–12.8). Clindamycin (RR 31.8, 95% CI 17.6–57.6), cephalosporins (RR 14.9, 95% CI 10.9–20.3) and gatifloxacin (RR 16.7, 95% CI 8.3–33.6) were associated with the highest risk. The RR for C. difficile infection associated with antibiotic exposure declined from 15.4 (95% CI 12.2–19.3) by about 20 days after exposure to 3.2 (95% CI 2.0–5.0) after 45 days. Use of a proton pump inhibitor was associated with increased risk (RR 1.6, 95% CI 1.3–2.0), as were concurrent diagnoses of inflammatory bowel disease (RR 4.1, 95% CI 2.6–6.6), irritable bowel syndrome (RR 3.4, 95% CI 2.3–5.0) and renal failure (RR 1.7, 95% CI 1.2–2.2).

JAMA Review (Jama 2009;301(9):954)

 

Recurrent

vanco 125 mg qid for 2 weeks

125 bid for 1 week

125 qd for 1 week

125 qod for 8 days

125 q 3 days for 15 days

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Hirschsprung’s

Acquired Megacolon-constipation leads to decreased bowel tone

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Diverticular Disease

most common in sigmoid

Diverticulitis-perf is complication, obstruction.  CT.  Use cefoxitin or Amp/Gent/Flagyl.  L sided appie

 

can form mesenteric phlegmon or abscess

 

Simple phlegmonous diverticulitis: treat conservatively. Allow patient oral fluids, pain control, and broad spectrum antibiotics. Cipro and flagyl or 2nd gen cephalosporin

 

Complicated Diverticulitis

 

Diverticulitis in Young Patients Diverticular disease is generally considered to be a disease of the elderly, but the incidence below age 40 is increasing. Studies conducted in the 1960s reported the incidence of diverticulosis to be lower than 5% in those under the age of 40; more recent studies suggest an incidence of 12–30% in this age group (1,2). Diverticulitis results from a microperforation of a diverticulum, which is usually quickly walled off by pericolic fat (causing only subclinical inflammation), but is sometimes poorly contained (resulting in free perforation and generalized peritonitis). The majority of affected patients complain of left lower quadrant pain of several days duration. Younger patients with diverticulitis are more likely to be male and obese (1,3). They often have atypical presentations – up to 25% present with right lower quadrant pain. Not surprisingly, the condition is often misdiagnosed. An abdominal CT scan can accurately establish the diagnosis, allows the clinician to avoid discharging the patient with “nonspecific abdominal pain”, and avoids delaying appropriate treatment. References: (1) Cole CD, et al. Case Series: Diverticulitis in the Young J of Emerg Med 2007;Articles in Press, published online 31 May 2007. (2) Biondo S, et al. Acute colonic diverticulitis in patients under 50 years of age Br J Surg 2002;89:1137–1141. (3) Marinella MA, et al. Acute diverticulitis in patients 40 years of age and younger Am J Emerg Med 2000;18:140–142. (EMEDHome)

 

From Michelle Lin:

Diverticulitis: Outpatient Treatment

Friend K, Mills AM. Is Outpatient Oral Antibiotic Therapy Safe and Effective for the Treatment of Acute Uncomplicated Diverticulitis? Annals of EM. 2011 – in press.

 

BOTTOM LINE: Uncomplicated diverticulitis might be treated as outpatient if:

·     Can tolerate POs

·     No significant comorbidities

·     Able to obtain antibiotics

·     Have adequate pain control

·     Access to followup and social support

 

Mizuki A, et al. Aliment Pharmacol Ther. 2005;21:889-97.

Prospective observ. study of outpatient abx treatment for diverticulitis in Japan

Diverticulitis diagnosis: Based on exam, blood tests, and ultrasound (no CT)

Inclusion criteria: Age < 80 years, diverticulitis

Exclusion criteria: “Severe” diverticulitis on ultrasound, uncontrolled DM, heart failure, renal dz, end-stage cancer, antibiotics within past 24 hrs.

Study group: n=70 during 1997-2002 period

Method: Day 4 and Day 7 followup

Result: 68 of 70 (97%) were successfully treated as outpatient

 

Ridgway PF, et al. Colorectal Dis. 2009;11:941-6.

Randomized controlled trial of IV vs PO antibiotics (cipro/metronidazole combo) for diverticulitis in Ireland. All patients admitted to hospital.

Diverticulitis diagnosis: Purely based on clinical exam (no imaging test).

Inclusion criteria: Left iliac fossa pain and LLQ abdominal tenderness

Exclusion criteria: Generalized abdominal tenderness or evidence of perforation

Study group: n=79 (41 with PO abx, 38 with IV abx)

Result: No difference in tenderness and days-to-resolution between groups.

 

Alonso S, et al. Colorectal Dis. 2009.

Cohort study with outpatient treatment using PO antibiotics (amox/clavulanic + metronidazole combo). All patients admitted to hospital.

Inclusion criteria: Diverticulitis diagnosis by clinical exam, labs, and CT imaging

Exclusion criteria: Unable to tolerate POs, comorbidities (DM, renal insufficiency, heart failure, COPD, no family support)

Study group: n=70

Methods: Follow-up 4-7 days after initial ED visit.

Result: 68 (97%) were successfully treated as outpatient. 2 (3%) failed outpatient tx because for increased abdominal pain (1) and vomiting (1).

 

Etzioni DA, et al. Dis Colon Rectum. 2010;53:861-865.

Retrospective study of outpatient diverticulitis patients

Diverticulitis diagnosis by clinical exam, labs, and CT

Inclusion criteria: Outpatient diverticulitis patients

Exclusion criteria: Prior dx of diverticulitis, colorectal cancer, inflammatory bowel dz

Study group: n=693 outpatient diverticulitis patients

Result: 554 (94%) were successfully treated as outpatient.

Predictors of treatment failure:

· Female: OR = 3.08 [1.31-7.28]

· Free fluid on CT: OR = 3.19 [1.45-7.05]

· WBC, perforation, abscess, phlegmon were not predictive (OR crossed 1.0)

 

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Large Bowel Obstruction

carcinoma, diverticulitis, volvulus (sigmoid from chronic constipation, try decompression.  Cecal from congenital lack of fixation)

 

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Post-Op Ileus

1 day for ascending colon

3 days for descending

much longer if complications arise

 

neostigmine dosing 0.5-1 mg over 4 hours QD

 

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Intussusception

70-90% of adults will have a cause discovered unlike peds in whom most cases are idiopathic

66% will have neoplasms found as the cause

Sx are usually present for a month prior to presentation, presents with N/V, change in bowel habits, melena, weight loss.

Peutz-Jeghers, an autosomal dominant disease causing GI polyps is also a possible cause.  (JEM 3/2003)

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Sigmoid Volvulus

Case 2:  A 84-year-old female presents with a one-week history of abdominal pain and distention. She was seen by her PMD for the same 2 days ago with a reportedly benign exam and was diagnosed with constipation, and given instructions to take milk of magnesia. She returned to her PMD today with increased pain and distention and was sent to the ED for further evaluation.  The patient is unable to describe the pain but localized it to the lower abdomen. She has been eating normally without nausea and has had no BM for 1 week. Her daughter requests that she be given pain medicine immediately for the pain. PMH: Hypothyroidism, Hip fracture, DVT, and Alzheimer’s.  Meds: Synthroid, KCl, Indapamide, Aricept, ASA.

 

Physical Exam: Thin black  female in mild to moderate pain. Vitals include HR 120, BP 84/55, RR 20, T 36.7°C, O2 Sat 96% on RA.   HEENT: nl, Chest: Tachy RRR, Lungs clear, Abdomen: distended with diffuse tenderness and rebound. Neuro: baseline dementia, otherwise normal. Stool: heme negative

 

Differential Diagnosis:

 

·      AAA

·      Cholecystitis

·      Mesenteric ischemia

·      Pancreatitis

·      Perforated viscus

·      Small bowel obstruction

·      Volvulus

 

What elements of the physical are missing? What tests will help you? Can this patient be given pain medicine?

 

Use of pain medicine for patients with abdominal pain

·      The common practice of withholding pain medicine from patients with abdominal pain for fear of altering the exam and clouding the diagnosis is not supported in the literature.

·      All available studies (Attard, LoVecchio, Mahadevan, Pace, Vermeulen, Zoltie) on this topic show that pain medicine, indeed, relieves suffering versus placebo without altering diagnostic abilities of clinicians.

·      Many studies show that the use of pain medicine even aids the clinician in making the correct diagnosis.

·      Study to prove no adverse effects from pain medicine would require 1,500 patients and has yet to be done. (Lee)

·      In many cases, it is reasonable to negotiate with the surgical consult that may not be familiar with or agree with the literature support for analgesics in abdominal pain.  For example: if the consult will be delayed more that 15 or 20 minutes, then a short acting narcotic, such as fentanyl, will be given prior to consult exam.

 

Case 2: Additional information

 

EKG: Sinus tachycardia, no old EKG

UA: RBC 4, WBC 13

Lytes: normal except Cr 2.2

CBC: Hct 40.5 WBC 25 Platelets 310

 

Another case of urosepsis and constipation in the elderly?

 

Is there a role for plain abdominal radiographs in this patient?

 

KUB shown below:

 

Case 2: ED course

 

The patient becomes more tachypnic and her oxygen saturation falls to the low 80’s.

 

What is the next step?

 

Our patient was intubated, given antibiotics, and taken to the operating room. She became hypotensive and required dopamine intraoperatively. In surgery, 63 cm of necrotic sigmoid colon was resected leaving the patient with a colostomy and a rectal Hartmann pouch.

 

Sigmoid Volvulus:

Pathophysiology:

·      Rotation of bowel segment around its mesenteric axis leading to luminal obstruction, vascular insufficiency, and eventual bowel necrosis.

Epidemiology:

·      Causes 5-6% of all large bowel obstructions (3rd leading cause after cancer and diverticulitis).

·      Occurs most often in inactive elderly with debilitating diseases.

·      Also occurs in patients with severe psychiatric or neurologic diseases.

Etiology:

·      Often due to severe, chronic constipation.

Signs/Symptoms:

·      Early symptoms – intermittent cramping, lower abdominal pain, and distention.

·      Later symptoms – nausea, vomiting, dehydration, obstipation (vomiting and obstipation often not present as in this case).

·      May have a history of similar episodes that resolved spontaneously.

·      Physical exam – moderate abdominal tenderness, but may not be impressive.

·      Fever, marked tenderness, and peritonitis are late findings and suggest bowel ischemia.

·      Mortality 20% overall, 53% when bowel is gangrenous.

Diagnosis:

·      One of the few diagnoses made on plane films (at least 80% of the time)

1)   Severely dilated single loop of colon in left abdomen

2)   Both ends in pelvis and bowel pointing superiorly (“bent innertube sign”)

·      Water soluble or barium enema confirms the diagnosis

1)   “Bird’s beak” deformity at the point of twists

2)   Cut-off of contrast flow into proximal colon

Treatment:

·      Surgery for gangrenous bowel or failed reduction.

·      For stable patients the volvulus can usually be reduced with sigmoidoscopy and rectal tube insertion.   (Successful 85%-95% of the time).

·      The rectal tube stents the bowel and prevents reoccurrence of the volvulus over the short term.

·      Recurrence rate is 90% if reduction is not followed by colopexy.

 

Remarkably our patient was extubated and weaned off of dopamine the day after surgery. She was discharged to home 6 days after surgery and continues to be a devoted patient of her primary care physician.

 

Teaching points

1)   Beware of the diagnosis of constipation in elderly patients with abdominal pain.

2)   Sigmoid volvulus may present with out significant symptoms of obstruction.

3)   Add volvulus to your list of reasons to obtain abdominal radiographs in the patients with abdominal pain.

 

References

 

Adam DJ, Bradbury AW, Stuart WP, et al. The value of CT in the assessment of suspected ruptured AAA. J Vasc Surg 1998;27:431-437.

 

Attard AR, Corlett MJ, Kidner NJ, et al. Safety of early pain relief for acute abdominal pin. BMJ 1992;305:554-556.

 

Balthazar EJ, Yen BC, Gordon RB. Ischemic colitis: CT evaluation of 54 cases. Radiology 1999;211:381-388.

 

Bickell WH, Wall MJ, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med 1994;331:1105-1109.

 

Blum U; Langer M; Spillner G; Mialhe C; et al. Abdominal aortic aneurysms: preliminary technical and clinical results with transfemoral placement of endovascular self-expanding stent-grafts. Radiology, 1996 Jan, 198(1):25-31.

 

Brennan DF. Ectopic Pregnancy- Part I: Clinical and Laboratory Diagnosis. Academic Emergency Medicine 1995;2:1081-1088.

 

Brennan DF. Ectopic Pregnancy- Part II: Diagnostic Procedures and Imaging. Academic Emergency Medicine 1995;2:1090-101097.

 

Buckley RG, King KJ, Disney JK, et al. Serum progesterone testing to predict ectopic pregnancy in symptomatic first-trimester patients. Ann Emerg Med 2000;36:95-100.

 

Castellone JA, Powers RD. Ischemic Bowel Syndromes: A Comprehensive, State-of-the-Art Approach to emergency diagnosis and management. Emergency Medicine Reports 1997;18:189-200.

 

Casto MA, Shipp TD, Casto EE, et al. The use of helical CT in pregnancy for the diagnosis of acute appendicitis. Amer Jo Obstet Gyn 2001;184:954-957.

 

Chou CK, Tsai TC. Small bowel volvulus. Abdom Imaging 1995;20:431-435.

 

Dart RG, Kaplan B, Cox C. Transvaginal ultrasound in patients with low β-hCG values: how often is the study diagnostic? Ann Emerg Med 1997;30:135-140.

 

Dart RG, Dart L, Mitchell P, Berty C. The predictive value of endometrial stripe thickness in patients with suspected ectopic pregnancy who have an empty uterus at ultrasonaography. Academic Emergency Medicine 1999;6:602-609.

 

Fenjo G. Acute abdominal disease in the elderly. Am J Surg 1982;143:751-754.

 

Funaki B, Grosskreukz SR, Funaki CN. Using unenhanced helical CT with enteric contrast material for suspected appendicitis in patients treated at a community hospital. AJR 1998;171:997-1001.

 

Gore RM, Miller FH, Pereles FS, et al. Helical CT in the evaluation of the acute abdomen. 2000;174:901-913.

 

Gurleyik E, Gurleyik G. Small Bowel Volvulus: a common cause of mechanical obstruction in our region. Eur J Surg 1998;164:51-55.

 

Hallan S, Asberg A. The accuracy of C-reactive protein in diagnosing acute appendicitis – a meta-analysis. Scan J Clin Lab Invest 1997;57:373-380.

 

Hörmann M, Paya K, Eibenberger K, et al. MR Imaging in children with nonperforated acute appendicitis. Amer Jo Radiology 1998;171:1998.

 

Klempnauer J; Grothues F; Bektas H; Pichlmayr R.  Long-term results after surgery for acute mesenteric ischemia.  Surgery 1997 Mar, 121(3):239-43.

 

Kuhn M, Bonnin RLL, Davey MJ, et al. Emergency department ultrasound scanning for abdominal aortic aneurysm: accessible, accurate, and advantageous. Ann Emerg Med 2000;36:219-223.

 

Lederle FA, Simel DL. Does this patient have abdominal aortic aneurysm? JAMA 1999;281:77-82.

 

Lee JS, Stiell IG, Wells GA, et al. Adverse outcomes and opiod analgesic administration in acute abdominal pain. AEM 2000;7:980-987.

 

Leo PJ, Simonain HG. The role of serum phosphate level and acute ischemic bowel disease. Amer Jo of Emerg Med 1996;14:??

 

Lim HK, et al. Diagnosis of acute appendicitis in pregnant women: values of sonography. Am J Roent 1992;159:539-

 

Loh YH, Dunn GD, CT features of small bowel volvulus. Aust Radio 2000;464-467.

 

LoVecchio F, Oster N, Sturmann K, et al. The use of analgesics in patients with acute abdominal pain. J Emerg Med 1997;15:775-779.

 

Lowe LH, Penney MW, Stein SM, et al. Unenhanced limited CT of the abdomen in the diagnosis of appendicitis in children: comparison with sonograpy. AJR 2001;176:31-35.

 

Mader TJ.  Acute diverticulitis in young adults.  Journal of Emergency Medicine, 1994 Nov-Dec, 12(6):779-82.

 

Maenza RL, Smith L, Wolfson AB. The myth of the fecalith. Amer jo Emerg Med 1996;14:394-397.

 

Mahadevan M, Graff L. Prospective randomized study of analgesic use for ED patients with RLQ abdominal pain. Amer Jo Emerg Med 2000;18:753-756.

 

Nachmann MM, Harkaway RC, Summerton SL, et al. Helical CT scanning: the primary imaging modality for acute flank pain. Amer Jo Emerg Med 2000;18:649-652.

 

Ohki T, Veith FJ. Endovascular grafts and other image-guided catheter-based adjuncts to improve the treatment of ruptured aortoiliac aneurysms. Ann Surg 2000;232;

 

Orr RK, Porter D, Hartman D. Ultrasound to evaluate adults for appendicitis: decision making based on meta-analysis and probabilistic reasoning. Acad Emerg Med 1995;2:644-650.

 

Pace S, Burke TF. Intravenous morphine for early pain relief in patients with acute abdominal pain. Acad Emerg Med 1996;3:1086-1092.

 

Pomper SR, Fiorillo, MA; Anderson, CW; Kopatsis, A.Hematuria associated with ruptured abdominal aortic aneurysms . Int Surg 1995;80:261.

 

Rao PM, Rhea JT, Novelline et al. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. New Eng Jo of Med 1998;338:141-146.

 

Rao PM; Rhea JT; Novelline RA. Sensitivity and specificity of the individual CT signs of appendicitis: experience with 200 helical appendiceal CT examinations.

Journal of Computer Assisted Tomography, 1997 Sep-Oct, 21(5):686-92.

 

Rao PM, Rhea JT, Rao JA, Conn AKT. Plain abdominal radiography in clinically suspected appendicitis: diagnostic yield, resource use, and comparison with CT. American Journal of Emergency Medicine, 1999;17:325-335.

 

Rao PM; Rhea JT; Novelline RA; McCabe CJ. The computed tomography appearance of recurrent and chronic appendicitis. American Journal of Emergency Medicine, 1998 Jan, 16(1):26-33.

 

Rao PM; Rhea JT; Novelline RA; McCabe CJ; Lawrason JN; Berger DL; Sacknoff R.Helical CT technique for the diagnosis of appendicitis: prospective evaluation of a focused appendix CT examination. Radiology, 1997 Jan, 202(1):139-44.

 

Rao PM. CT for suspected appendicitis. AJR 1999;1447-1448. (Letter)

 

Rao PM, Rhea JT, Novelline RA,  et al. Helical CT with only colonic contrast material for diagnosing diverticulitis: Prospective evaluation of 150 patients. AJR 1998;170:1445-1449.

 

Regan F, Karlstad RR, Magnuson TH. Minimally invasive management of acute superior mesenteric artery occlusion: combined urokinase and laparoscopic therapy. Amer Jo of Gastroenterology 1996;91:1019-1021.

 

Rha SE, Ha HK, Lee SO, et al. CT and MR imaging findings of bowel ischemia from various primary causes. Radiographics 2000;20:29-42.

 

Robinson D, Englund R, Hanel KC. Treatment of abdominal aortic aneurysm disease in the 9th and 10th decades of life. Australian and New Zealand Journal of Surgery 1997;67:640-642.

 

Rothrock SG. Misdiagnosis of appendicitis in nonpregnant women of childbearing age. J Emerg Med 1995;13:1

 

Rothrock SG. Overcoming limitations and pitfalls in the diagnosis of acute appendicits. Emergency Medicine Reports 1992;13:41-52.

 

Satta J, Leaearea E, Reinilea, et al. Rupture type determines the outcome for ruptured AAA patients. Annnals Chirurgiae et Gynaecologiae 1997;86:24-29.

 

Schnieder TA, Longo WE, Ure T, Vernava AM. Mesenteric Ischemia: acute arterial syndromes. Dis Colon Rectum 1994;37:1163-1174.

 

Snyder BK, Hayden SR. Accuracy of leukocyte count in the diagnosis of acute appendicitis. Ann Emerg Med;33:565-574.

 

Spivak H; Weinrauch S; Harvey JC; Surick B; Ferstenberg H; Friedman I. Acute colonic diverticulitis in the young. Diseases of the Colon and Rectum, 1997 May, 40(5):570-4.

 

Stovall TG, Kellerman AL, Ling FW, et al. Emergency department diagnosis of ectopic pregnancy. Ann Emerg Med 1990;19:1098-1103.

 

Taourel P, Deneuville M, Praden J, et al. Acute mesenteric ischemia: diagnosis with contrast enhanced CT. Radiology 1996;199:632-636.

 

Tilden FF, Powers RD. Ectopic Pregnancy: avoiding missed diagnosis and reducing morbidity. Emergency Medicine Reports 1996;17:199-205.

 

Vermeulen B, Morabia A, Unger PF, et al. Acute appendicitis: influence of early pain relief on the accuracy of clinical and US findings in the decision to operate – a randomized trial. Radiology 1999;210:639-643.

 

Vignati PV; Welch JP; Cohen JL.  Long-term management of diverticulitis in young patients. Diseases of the Colon and Rectum, 1995 Jun, 38(6):627-9.

 

Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? Jama 1996;276:1589-1594.

 

Weltman DI, Yu J, Krumenachker J, et al. Diagnosis of acute appendicitis: comparison of 5- and 10-mm CT sections in the same patient. Radiology 2000;216:172-177.

 

Wise SW, Labuski MR, Kasales CJ, et al. Comparative assessment of CT and Sonographic Techniques for appendiceal imaging. AJR 2001;176:933-941.

 

Zoltie M, Cust MP. Analgesia in the acute abdomen. Annals of the Royal College of Surgeons of England 1986;68:209-210.

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Sigmoid Volvulus

Common in the elderly from constipation or chronic inactivity

both ends of the loop of distended bowel will point towards the pelvis.

need rectal tube decompression

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Cecal Volvulus

any age, but commonly in young people

high mortality

 

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Inflammatory Bowel Disease (IBD)

Ulcerative Colitis

arthritis, erythema nodusum, pyoderma gangrenosum, ascending cholangitis, uveitis

Ulcerative Colitis: A recurrent inflammatory process involving the mucosa and submucosa of the colon and rectum Epidemiology- prevalence ranges from 37.5-229 per 100,000 persons -males > females -in men incidence peaks in the 30’s -more common in urban areas -found almost exclusively in industrialized nations Pathophysiology-50% begin in colon and stay there -30% pass the colon -20% pancolitis with no skip areas as seen with Crohn’s disease -Crypt abscesses leads to inflammatory cell migration with loss of colonic structure and subsequent inability to absorb water and sodium all associated with protein loss -Submucosal vessel repair occurs with resultant inflammation rate greater than repair (blood and pus), the mucosa hypertrophies and then you get reversible strictures with spasm -Finally the colon becomes foreshortened, rigid, straight and subsequently lacks the haustral markings -In severe cases, the typical mucosal appearance consists of thick inflammatory exudates composed of blood, pus, and mucus covering irregular, shallow ulcers Clinical presentation: Initially can present with a wide spectrum of severity with only a small percentage presenting with the classical symptoms of: -fever, crampy abdominal pain, tenesmus, urgency -frequent, painful passage of stools with blood, pus, and mucus -Majority of patients present with cyclical diarrheal/fever/tensesmus/crampy abdominal pain/anorexia/weight loss, which is often insidious in onset -diarrhea may not be bloody -Can also present with acute exacerbations of known disease -Characterized by relapses and acute exacerbations with complete resolution in between attacks -Recurrences often associated with emotional stress, infections or other acute illnesses, pregnancy, use of cathartics and antibiotics, or withdrawal of therapeutic medications -Extracolonic manifestations in up to 25% of cases to include: Musculoskeletal: -rheumatologic disorders including peripheral/axial arthropathy -up to 5-20% of cases of UC -metabolic bone disorders including osteoporosis and osteopenia -23-59% of patients Dermatologic: -Erythema nodosum in 10-20% of cases “Osis and It is” of the Gut: An Update Kurtis Holt, MD ACEP Scientific Assembly October 2002 -Pyoderma gangrenosum in 1-10% of cases -Sweet’s syndrome (acute febrile neutrophilic dermatosis) -apthous ulcers -pyoderma vegetans -Epidermolysis bullosa acquisita Mild- 60% of cases -limited to rectum in 80% of cases with <4 stools per day with or without blood -no fevers, tachycardia, or anemia and a normal ESR Moderate-25% of cases -disease extends into the ascending colon with > 4 large stools per day -mild fever and tachycardia Severe disease- 15% of patients -disease limited to left colon in only 10% of cases with >6 bloody stools per day -fever, tachycardia, anemia, and dehydration are hallmarks -associated laboratory abnormalities include hypoalbuminemia, elevated ESR and relapses/recurrences are frequently associated with extraintestinal manifestations Pediatrics- often have significantly more extensive disease with the same symptoms as adults but differ in that the extraintestinal manifestations may be dominant -often associated with growth failure, arthropathy, and liver disease Diagnosis: Once thought to be the diagnostic method of choice, Barium enemas are no longer recommended to make the initial diagnosis or in the cases of acute relapses -predispose to toxic megacolon -diagnosis of UC should be considered in anyone who presents with bloody diarrhea and the right clinical scenerio -quickly becoming the procedure of choice for bloody stools, ENDOSCOPY a long with intestinal biopsy, is the most accurate method for diagnoses -also rules out/in other potentially dangerous diagnosis ED diagnosis- clinical grounds, more importantly? -rule out other life threatening diseases/lesions Other radiologic studies AAS- rule out obstruction/toxic megacolon CT scan- rule out other life threatening entities Complications: Toxic Megacolon- occurs in up to 5% of cases -dilated colon >5-6 cm with loss of haustral markings on AAS -septic, apathetic, lethargic, pain/distension/tenderness ->10 bowel movements per day -predisposing factors -discontinuing medications -barium enema -colonoscopy -cessation of smoking “Osis and It is” of the Gut: An Update Kurtis Holt, MD ACEP Scientific Assembly October 2002 -motility-affecting drugs

ED Treatment: Mild to Moderate disease -outpatient management with prednisone 40mg/day -topical steroids with steroid enemas -sulfasalazine at 500mg po QID -mesalamine 5-ASA (newer more expensive) available -increase fiber in diet and AVOID anti-diarrheals -close follow up with primary care, especially if started on new meds Severe disease- ADMISSION -IV fluids and correction of electrolyte abnormalities -hydrocortisone 100mg IV or methylprednisolone 20mg IV -referral to general surgery for evaluation for possible colectomy

Crohn’s Disease

Crohn’s Disease- a chronic inflammatory bowel condition affecting any part of the GI tract -also referred to as “terminal ileitis”, “regional enteritis”, “granulomatous ileocolitis” Epidemiology- 30-60 persons per 100,000 in the US -incidence doubling every 10 years -onset generally between the ages of 15 and 40 with both sexes involved equally -8 times more likely in the Jewish population Pathophysiology- TRANSMURAL inflammation -may involve adjacent lymph nodes -20% have colonic involvement alone and of those patients with small bowel disease 30% will develop coexisting colon involvement -50% both colon and ileum -more likely to affect other organ systems Distinguishing factors -involves all layers of the bowel (into serosa) -not continuous i.e. “skip areas” -rectal involvement is not common -but anal and rectal fistulas/abscesses are -characteristic small bowel involvement -grossly bloody stools much less common Clinical Presentation- patients will have one of three patterns of disease -inflammatory disease -strictures -fistulas -similar to UC but more variable and usually worse with 80% of the cases having -abdominal pain and cramps -fever, anorexia, and diarrhea -weight loss “Osis and It is” of the Gut: An Update Kurtis Holt, MD ACEP Scientific Assembly October 2002 Extraintestinal manifestations Hydronephrosis secondary to involvement of the right ureter

Nephrolithiasis secondary to increased oxalate absorption in the damaged small bowel Hepatobiliary- 50% of patients with IBD -gallstones found in 13-34% -hepatic steatosis most common -5% of patients found to have primary sclerosing cholangitis (PSC) -75% of patients with PSC found to have UC -uncommon -pericholangitis, chronic hepatitis, cholangiocarcinoma -rare -pancreatitis, haptic amyloidosis, granulomatis hepatitis Arthritis-20% -ankylosing spondylitis -peripheral arthritis of knees, ankles, wris ts and fingers Vascular-6% -thromboembolic, vasculitis, arteritis -mortality rate 25% making it the 3rd leading cause of death Dermataologic-15% -more common in women -erythema nodosum, pyoderma gangrenosum, -occular complications such as episcleritis and uveitis Diagnosis: Can be difficult as many of these patients will present with the extraintestinal manifestations discussed Clues- presence or history of anorectal problems (fistulas/abscesses) Radiologic imaging similar to US with CT mainly used to rule out other entities or rule out abscess secondary to the disease Diagnosis most likely confirmed by sigmoidoscopy with rectal biopsy CT f indings UC vs Crohn’s -wall thickness >2cm in Crohn’s, <1.5 in UC -small bowel uninvolved in UC -perirectal and perisacral fat presence in UC -mesenteric stranding with Crohn’s -rectum uninvolved in Crohn’s ED Treatment: Very similar to UC with the only difference being the addition of Metronidazole which has been found to be helpful, otherwise in both UC and Crohn’s routine administration of antibiotics is not recommended unless a suppurative complication (abscess) has been found Enteric coated fish oil has been shown to reduce the frequency of relapses Disposition: similar to UC. Newly diagnosed cases of UC and Crohn’s are generally admitted to facilitate an expeditious work-up and medical management in coordination with the patient’s primary care physicianFlagyl

 

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Ischemic Colitis

Reduction in blood flow to the IMA and SMA colonic collaterals

splenic flexure in 75% of cases.

Most are transient.  Lower abd pain, 24 hrs of bloody diarrhea.  Abdominal pain can precede bloody diarrhea.

young female joggers on OCPs also get ischemic colitis

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Radiation Proctocolitis

leads to stricture or bleeding

miserable disease

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Primary Epiploic Appendagitis

Torsion of epiploic appendage.  Tend to be younger than diverticulitis pts (35 vs. 55), pain was rapid onset, constant, localized to LLQ.  Usually presents s rebound c normal labs.  Diverticulitis is usually much more diffuse and has rebound.

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Irritable Bowel Syndrome (IBS)

Presence for at least 12 weeks during past year of abdominal pain/discomfort with 2 of 3:

• Relieved by defecation
• Onset associated with a change in the frequency of defecation
• Change in the form of the stool

Alarm Symptoms:  GI bleeding, anorexia or weight loss, fever, persistent diarrhea resulting in dehydration, nocturnal symptoms, severe constipation or fecal impaction, Family history of GI cancer, IBD, or celiac sprue, onset after 45 years old.

 

Work-up for primary care initial diagnosis:  CBC, ESR, Lytes, TFTs.  Eventual flex sig.

 

Low dose antidepressants such as desipramine (50-150 mg) or amitriptyline (25 to 100 mg) have been found to be effective in eliminating the abdominal pain of IBS.  SSRIs may also work, but experience is limited.

 

Volume 53, Issue 06 March 21, 2006

NEW APPROACHES TO IRRITABLE BOWEL SYNDROME

Richard A. Weisiger, MD, PhD, Professor, Department of Medicine, and

Director, Gastrointestinal Faculty Practice, University of California,

San Francisco, School of Medicine

Irritable bowel syndrome (IBS):

group of functional bowel

disorders; predominant features include abdominal pain or discomfort

associated with defecation or change in bowel habit

and disordered defecation (constipation, diarrhea, or combination);

prevalence

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